Provider Demographics
NPI:1730591702
Name:BULLOCK, YVETTE (COSMOLOGIST HAIR REP)
Entity type:Individual
Prefix:
First Name:YVETTE
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:COSMOLOGIST HAIR REP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 WATERDOWN DR
Mailing Address - Street 2:10
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-4545
Mailing Address - Country:US
Mailing Address - Phone:910-850-6631
Mailing Address - Fax:877-463-6834
Practice Address - Street 1:275 WATERDOWN DR
Practice Address - Street 2:10
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-4545
Practice Address - Country:US
Practice Address - Phone:910-850-6631
Practice Address - Fax:877-463-6834
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-27
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC3334171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor